BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire May 2012 TOPICAL FLUORIDE VARNISH Group Health Cooperative of Eau Claire may contract for dental fluoride varnish services provided by the County. Please refer to the Provider Services Agreement to determine if these services will be reimbursed by Group Health Cooperative of Eau Claire. Topical applications of fluoride may be provided by nurses and dental hygienists employed by certified HealthCheck nursing agencies. Nurses may provide topical fluoride applications at a HealthCheck nursing agency under a physician’s order or agency’s protocol. Dental hygienists may provide topical fluoride applications at a HealthCheck nursing agency under a dentist or physician’s order, or agency protocol. Over-the-Counter Fluoride treatments are NOT covered. * Please refer to the ForwardHealth website for the most current coding information. EMERGENCY DETENTION ADMISSIONS This section discusses the coordination of services between County Agencies and HMOs for substance abuse and behavioral health coverage, and defines responsibilities for the admission and billing of services provided to clients enrolled in BadgerCare Plus or Medicaid SSI Managed Care. Emergency Detention Admissions For admissions that result from an Emergency Detention, the client’s healthcare coverage should be verified and the HMO informed of the admission within the first 72 hours (three business days plus any intervening weekend days and/or holidays). The County should contact the HMO to discuss authorization and treatment plan options, as soon as they become aware of the admission. The HMO is responsible for the cost of Emergency Detention and court-related mental health/substance abuse treatment, including involuntary commitment provided out-of-network. Treatment provided by out-of-network providers will be covered only if the time needed to obtain treatment in-network would have risked permanent damage to the enrollee’s health or safety, or the health or safety of others. For Other Admissions (other than Emergency Detentions) The County must contact the HMO prior to the client’s admission to discuss authorization and treatment plan options. As part of the case management responsibilities, the HMO may suggest alternate care options. Placement The County Agency and HMO staff will work together to ensure the most appropriate placement and services are provided to the client. The County and/or corporation counsel are responsible for informing the judge of the HMO’s network recommendations. [88]
BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire May 2012 If the individual is enrolled in a Medicaid HMO at the time of admission, the HMO is responsible for care provided during the first 72 hours (three business days plus any intervening weekend days and/or legal holidays) when there is a statement of Emergency Detention (ED) or detention order. During this period of time, care is deemed medically necessary. The HMO is responsible for court-ordered treatment beyond the mandatory 72 hours and any intervening weekend days or holidays, if they are involved in the discharge planning at an out-of-network facility, or if additional care is provided at a network facility. If the individual is not enrolled in a Medicaid Program at the time of admission, the admitting facility will submit a Medicaid application regardless of expected length of stay. Medicaid fee-for-service remains the payer for the duration of the stay, even if the individual subsequently enrolls in the HMO. PRENATAL CARE COORDINATION – MEDICALLY NECESSARY SERVICES Prenatal Care Coordination (PNCC) services are reimbursed by the Medicaid fee-for-service Program for all clients, including those enrolled in HMOs. The PNCC Agency is responsible for services that include outreach, risk assessment, care planning, care coordination, and follow up to support high-risk pregnant women. The HMOs are responsible for coordinating care and managing medically necessary services. The successful provision of services to clients requires cooperation, coordination, and communication between the HMO and the PNCC Agency. Fee-for-Service The following services are not reimbursed by the HMO, but are submitted to the state for reimbursement as feefor-service: • Outreach • Assessments • Care plan development and Case management • Health education and nutrition counseling • Care coordination and monitoring Coordination of Care between the County and HMO It is important for Counties and HMOs to coordinate care and work together to ensure healthy outcomes for their clients and members. The successful provision of services requires cooperation, coordination and communication between the HMO and the PNCC. Coordination of care can improve communication between all members of the health care team; encourage the timely sharing of information; avoid duplication of services; support care plans; and offer resources to each other. [89]
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